Introduction
This chapter focuses upon the intrinsic barriers (within the individual) and extrinsic barriers (within the health care situation) that may impede health care professionals’ ability to provide spiritual care. The chapter will explore in detail the barriers that exist in practice, presenting some strategies and solutions that may empower health care professionals better to meet an individual’s spiritual needs. Case studies are used to generate a deeper awareness and insight into the barriers identified that result in spiritual needs remaining unmet.
Activity 5.1
Using material explored earlier in this book, can you identify any barriers that may prevent health care professionals from addressing or meeting their patients’ spiritual needs?
Having reflected upon the case studies presented in earlier chapters, you may have identified several points such as a lack of privacy, fear or ignorance. On closer inspection of your list, you may note that the barriers can be placed into different categories: those that arise from within the health care professional or patient/service user; those concerned with communication; and a further selection that appear on initial reflection to be beyond the control of the health care professional or patient. These barriers will now be explored in greater detail (Box 5.1).
Box 5.1 The two main categories of barriers
Intrinsic
The word ‘intrinsic’ is used in this context to mean any factor arising within an individual that may affect the provision of spiritual care.
Extrinsic
The word ‘extrinsic’ is used to describe factors that arise beyond the control of an individual, which prevent or inhibit the provision of spiritual care.
Identifying the barriers
The growing realization that health care professionals can play a fundamental role in the provision of spiritual care has witnessed a proliferation in the amount of published material discussing this issue. This is evident in Box 2.1, Chapter 2.
CAUTION
When reviewing the literature concerning health care professionals’ ability to provide spiritual care, the professions are at risk of being dogmatic. Many articles published suggest that health care professionals should be providing spiritual care irrespective of patients’ or service users’ wishes. This tendency towards being over-prescriptive must be considered when examining the barriers that may prevent health care professionals from providing spiritual care, because such dogmatism may be unjustified.
Meeting the spiritual needs of patients can be uncomfortable for the nurse. Several reasons for such discomforts include embarrassment, the belief that it is not the nurse’s role, lack of training, and lack of own spiritual resources.
This quotation seems more balanced, emphasizing that the provision of spiritual care is not simple and straightforward because there are many factors that must be considered. A comparison of Soeken and Carson’s quotation with your own list of barriers may reveal similarities.
Research undertaken by a wide range of health care professionals has revealed barriers similar to those identified by Soeken and Carson. Ross (1994, 1997) identified that barriers could be nurse or patient related, profession related, or environmentally related. McSherry (1997) highlighted barriers similar in nature, describing them as economic, educational, environmental or personal in origin. Interestingly, these barriers still exist despite all the attempts to raise the profile of spiritual care and integrate it within care delivery. These barriers are not just specific to nursing. McColl (2000, p.225), writing on the subject of spirituality within occupational therapy practice, recognizes the fears and anxieties that practitioners face: ‘After all, if we did Do something or encouraged a client to Do something of a spiritual nature and it backfired, how could we defend ourselves?’
Achieving positive spiritual care
Figure 5.1 illustrates how the successful provision of spiritual care is dependent upon three key areas – the health care professional, the patient/service user, and the economic and environmental context in which spiritual care is provided. It is suggested that for spiritual care to be effective all these three areas must be working in relative harmony. Barriers manifesting themselves in any of these areas will result in the patient’s or service user’s spiritual needs not necessarily being met. Intrinsic and extrinsic barriers to providing spiritual care will now be discussed in more detail.
Figure 5.1: The three areas in which barriers may occur
Intrinsic barriers
I would probably rather tell you about my sex life than about my spiritual life. And I’m fairly sure you would be more scandalized to find a Bible at the bottom of my briefcase than a copy of the Kama Sutra. (Allen 1991, p.52)
Charlotte Allen’s quotation highlights the deeply personal aspects of spirituality, indicating that there are many personal barriers (intrinsic) that prevent us from addressing this dimension of care with individuals. It would seem that in today’s society individuals feel more comfortable talking about sexuality and elimination than about spiritual matters. Implicit in the quotation is the notion that barriers in the provision of spiritual care may not only originate from within the patient, but also from within the nurse or health care professional. The provision of spiritual care is an exchange of energy – an encounter – between two individuals: the health care professional and the service user, the doctor and the patient, or the patient and his or her own spiritual leader. Therefore, barriers in the exchange of this energy may arise from within any of these key individuals.
The intrinsic barriers that may prevent the provision of spiritual care are not specific to the patient. Figure 5.1 shows that the provision of spiritual care is a two-way process between the patient/service user and the health care professional (Clark et al. 1991). Therefore, an intrinsic barrier may develop within either the health care professional or the patient/service user, preventing spiritual needs from being addressed. Some of the intrinsic barriers that may arise are listed in Box 5.2. Researchers, as outlined earlier, have identified several of these barriers (McSherry 1997; Waugh 1992).
Intrinsic barriers may be associated with our own personal belief systems, which may be in conflict with that of the patient. For example, our attitudes towards certain religious groups may be prejudiced by the beliefs and values we have acquired through socialization. Another example may be the attitudes we have towards different sections in society, such as the social stigma attached to HIV and AIDS or the misconceptions associated with asylum seekers, and the rise in ‘Islamaphobia’. Other barriers may occur because of our inability to communicate effectively with patients or our service users. The barriers listed in Box 5.2 are now discussed in detail.
Box 5.2 Intrinsic barriers
Inability to communicate through illness or loss of senses
Ambiguity
Lack of knowledge in the area of spirituality
Patient not aware of the concept of spiritual need
Sensitive area – too personal for nurses to address
Own personal beliefs and values
Emotionally demanding and fear-provoking
Fears – mismanagement
Prejudices
Inability to communicate through illness or loss of senses
McCavery (1985, p.130) stresses the importance of good communication in providing spiritual care: ‘In many ways, spiritual care is subjective, and its success rests upon the meaning of conversations between individual patients and nurse.’
Working from this quotation, a major obstacle in the provision of spiritual care is a breakdown in the channels of communication. Ross (1994) presents several conditions that can impede communication such as aphasia (loss of speech), or any other problem associated with the loss of a sense such as sight or hearing (see Case study 5.2). The inability to communicate effectively can result in an individual being unable to express a spiritual need, and the nurse being unable to assess or interpret the situation. The overall results of such situations may see the patient’s or service user’s spiritual needs remaining unrecognized and consequently unmet. This inability to communicate effectively can mean that the patient and nurse become frustrated. Such situations are not easy to resolve, as there are no easy solutions. The health care professional may use a variety of techniques to try to establish what the individual needs, such as writing needs down, using word charts, or even enlisting an interpreter to translate a patient’s or service user’s needs.
Another aspect of communication that can prove problematic is communicating effectively with individuals who may not have the intellectual development or capacity to think abstractly, such as young children, individuals with severe learning disabilities or clients with organic brain disease such as dementia (Case study 5.1).
This case study stresses the importance of providing spiritual care that is appropriate and at the correct level for individuals to comprehend. Sommer (1989, p.231) highlights some of the difficulties practitioners may face when attending to the spiritual needs of dying children:
Children can readily sense when adults are uncomfortable with a topic of discussion or a situation. Whereas healthy children like to express their uniqueness, sick and dying children like to find ways of blending in with the crowd.
The issues identified in this quotation are certainly evident in Samantha’s situation (Case study 5.1). The importance of good communication and interpersonal skills in managing such situations is paramount. If barriers exist that prevent channels of communication, then our human condition may result in avoidance of the situation. Samantha’s situation is difficult, with the potential for it to be emotionally demanding and exhausting. Such situations challenge and drain the emotional and spiritual reserves of the most experienced practitioners.
Ambiguity
Ambiguity is when uncertainty or a lack of insight into situations prevents either the nurse or the patient from entering into a therapeutic relationship. Numerous reasons for this may exist and it is not unique to the spiritual dimension. However, because of the deeply personal nature of spirituality, ambiguity may arise when the health care professional and patient/service user have contrasting belief systems and personalities. This can be illustrated by the situation where a health care professional – for example, a nurse who does not have any belief in God – is asked to be primary nurse for a patient who is a practising Christian attending a very Evangelical church. At every opportunity the patient tries to convert the nurse. This situation may arouse a great deal of insecurity, frustration and vulnerability within the nurse. The result may be that the nurse feels that his or her personal belief system is being challenged and, where possible, the nurse may avoid making any meaningful contact with the patient. Similarly, a nurse may have strong beliefs about the sanctity of life, and may decline to participate in the surgical procedure of termination of pregnancy.
Samantha is eight years of age and diagnosed with an inoperable terminal brain tumour. Samantha has been told about her condition and seems to avoid any mention of the issue. She keeps repeating time and again, ‘I do not want to die, Mammy’.
What do you feel are the intrinsic issues that may be barriers in providing adequate spiritual care?
The need for health care professionals to provide care that does not project their own personal beliefs onto patients or service users is evident. Within my own profession of nursing, two cases of Registered Nurses being brought before the Nursing and Midwifery Conduct Committee (formally the United Kingdom Central Council for Nursing and Midwifery) for professional misconduct have been documented (Castledine 2005, p.745; Cobb 2001, p.74). These cases serve as a stark warning for all health care professionals about the need for self-awareness.
Lack of knowledge in the area of spirituality
Ambiguity may also arise when the service user or health care professional does not know what is meant by the term ‘spiritual need’. On a cautionary note, just because an individual is not familiar with the language of spirituality does not mean that spiritual needs will go unmet. Draper and McSherry (2002, p.1) write:
We suggest that adequate conceptual vocabulary already exists to enable us to understand and support them (or at least to try) – this is the vocabulary of loss, grief, fear, anxiety, hope, despair, joy and realization, we can see no advantage in superimposing a further vocabulary of spirituality.
There is an urgent need for health care professionals to research more fully patients’ and health care professionals’ understanding of these terms. However, as Swinton and Narayanasamy (2002, p.158) correctly point out:
…we propose that it is reasonable to suggest that the spiritual dimension not only exists, but also should be taken seriously by all nurses who profess to offer holistic care. To dismiss the universality of spirituality summarily on the grounds of one study would appear to be unreasonable.
This quotation rightly alerts all health care professionals to the fact that there may well be numerous ways of defining spirituality, and that just because the language of spirituality may not always be recognized at a personal level by patients or service users does not mean the concept is obsolete. For ambiguity to be removed, health care professionals need to be introspective, being aware of their own personal beliefs, values and, importantly, prejudices. Reflecting upon practice or critical incidents that are encountered in relation to spiritual matters will enable practitioners to evaluate their own emotions and feelings, formulating strategies that will allow them perhaps to cope better or adjust their practice should similar situations be encountered in the future (McColl 2000; McSherry 1996, 2004).
Sensitive area – too personal for health care professionals to address
McSherry (1997) asked nurses to provide some qualitative responses into what they perceived were the main barriers in the provision of spiritual care. Several of the nurses surveyed indicated that the area of spirituality was too sensitive to be addressed by nurses. In fact, McSherry’s (2004) qualitative study, which included a broad range of health care professionals, confirmed this earlier finding. The notion of sensitivity included the nurses’ or health care professionals’ own fears of mismanagement of delicate and often deeply personal situations. Harrison (1993) highlighted a particular concern related to over-involvement in situations one cannot handle – ‘getting out of one’s depth’. Another aspect of sensitivity is the fear of knowing what to say when a patient or service user asks an awkward existential question, such as ‘Why me?’ or ‘What have I done to deserve this?’ This type of searching can challenge the health care professional, bringing into question his or her own personal spirituality or philosophies surrounding life, death and religion. It would appear that spiritual care extends health care beyond task focus and demands health care professionals to give of themselves and develop relationships, not just to perform tasks.
Emotionally demanding and fear-provoking
The information presented in relation to the intrinsic barriers indicates that there is an emotional cost or labour involved in the provision of spiritual care in that it can be emotionally and spiritually demanding. Tony Walter (2002, p.138), in his article titled ‘Spirituality in palliative care: opportunity or burden?’, raises some fundamental points about the assumption that all nurses or health care professionals can meet patients’ spiritual needs. He concludes his work with the following recommendation that has poignancy for all advocating spiritual care:
With careful attention being paid to each individual patient, and with knowledge of what each member of the team can and cannot offer, it may be possible to find someone who can accompany each patient at least a little of the way. But it need not be me. This should relieve each member of the team of the burden of feeling obliged to accompany each and every patient.
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